Difficulty: Medium
Average Score: 63%
Full-length
The nurse is using the Glascow coma scale to assess the client's motor response. The nurse places pressure at the base of the client's fingernail for 20 seconds. The client's only response is withdrawal of his hand. The nurse interprets the client's response as:
Correct answer
C
Rationale
Withdrawal of the hand to painful stimuli indicates a flexion response, scoring 4 on the Glasgow Coma Scale motor component.